2021_Book_TextbookOfPatientSafetyAndClin

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Patient Safety in Laboratory Medicine 24 Mario Plebani, Ada Aita, and Laura Sciacovelli Learning Objectives The notion of patient safety in laboratory medicine can be loosely interpreted as the assurance that harm to patients is prevented, safe care outcomes are enhanced through error prevention, and the system is continuously improved. However, this somewhat simplistic interpretation hides the concept’s true complexity. A clear definition of the laboratory professional’s role and competencies in the diagnostic process is therefore required, as is the use of suitable quality assurance tools. The concept of a “brain-to-brain loop” of laboratory testing encompasses the different steps involved, starting with appropriate test requesting and concluding with the appropriate use of laboratory information (Fig. 24.1). Moreover, it highlights the importance of integrating laboratory information in the care pathways, calling for system quality and patient safety, and also elucidates the value of laboratory medicine. M. Plebani (*) · A. Aita Department of Laboratory Medicine, University- Hospital of Padova, Padova, Italy Department of Medicine-DIMED, University of Padova, Padova, Italy e-mail: mario.plebani@unipd.it L. Sciacovelli Department of Laboratory Medicine, University- Hospital of Padova, Padova, Italy e-mail: laura.sciacovelli@aopd.veneto.it In the last few decades, changes in the nature of laboratory services have underscored a paradigmatic transformation of the laboratory scenario [1] thanks to technological innovation, the introduction of ever more complex tests in emerging diagnostic fields, more advanced diagnostics, and other internal and external drivers. The transformation will become even more marked in the future. In the ten points identified in the “Manifesto for the future of Laboratory Medicine professionals” (Table 24.1), great emphasis is placed on the importance of cooperation in reducing the risk of diagnostic errors, the implementation of reliable laboratory medicine stewardship, the involvement of laboratory medicine professionals in interdisciplinary teams, and the promotion of professional expertise. A large body of evidence demonstrates that this integration is crucial to the rational utilization of laboratory information [2]. The issue of patient safety, which impacts every diagnosis, involves numerous stakeholders. No single intervention to prevent errors is available, and there is a pressing need for the rigorous evaluation of possible solutions that will be beneficial, will obviate unintended consequences, and, above all, will safeguard patients. In the healthcare setting, medical laboratories should always be a driver in ensuring patient safety through: • The integration of laboratory professionals with new competencies and skills in © The Author(s) <strong>2021</strong> L. Donaldson et al. (eds.), Textbook of Patient Safety and Clinical Risk Management, https://doi.org/10.1007/978-3-030-59403-9_24 325
326 M. Plebani et al. Fig. 24.1 The brain-to-brain-loop: description of the total testing process (from reference 8 modified) Action Patient’s brain Physician’s brain Interpretation Laboratorian’s brain Ordering Reporting Collection Analysis Identification Preparation Transportation Table 24.1 Manifesto for the future of laboratory medicine professionals [1] 1. Convert results in clinical information 2. Cooperate in reducing the risk of diagnostic errors 3. Implement a reliable laboratory medicine stewardship 4. Combine data of all laboratories subspecialties and diagnostic imaging in the same report 5. Establish reliable reference ranges and decision limits 6. Facilitate more effective teamwork and be actively involved in interdisciplinary teams 7. Promote the shift from volume based reimbursement models to clinical values 8. Improve and update the way laboratory medicine is taught 9. Do not neglect administrative competence and duties 10. Promote the value of the profession multidisciplinary teams, in which all stakeholders are involved. • Awareness of the impact of laboratory errors in patient management. • The implementation of effective quality assurance tools to identify and prevent potential laboratory errors. 24.1 Epidemiology of Adverse Events 24.1.1 Laboratory Medicine as a Driver in Ensuring Patient Safety The phrase “clinical laboratory stewardship” effectively clarifies the indispensable role of
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Textbook of Patient Safety and Clin
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Liam Donaldson • Walter Ricciardi
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Foreword As a member of the 17th le
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Preface Despite the extensive atten
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Acknowledgements The volume editors
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xii Contents 11 Adverse Event Inves
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Part I Introduction
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4 explain how to prepare and update
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6 considered preventable) [11]. Fur
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8 W. Ricciardi and F. Cascini the l
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10 W. Ricciardi and F. Cascini inte
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12 maximized or perhaps even realiz
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14 steps in obtaining, managing, an
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16 quality improvement methodologie
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18 99. Morciano C, et al. Policies
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20 Reason travelled the world makin
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22 For each hospital unit, other do
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24 As head of clinical risk managem
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26 R. Tartaglia Table 2.1 Differenc
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28 R. Tartaglia Open Access This ch
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30 otherwise efficient brains lead
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32 • A routine violation is basic
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34 Table 3.1 Framework of contribut
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36 H. Higham and C. Vincent The con
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38 H. Higham and C. Vincent recogni
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40 H. Higham and C. Vincent Table 3
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42 assessment and prevention was no
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44 of human error, 2nd: 1983: Bella
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46 ment of theories on how to deliv
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48 all times, not only when there i
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50 healthcare, pursued by enthusias
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52 15. National Academies of Scienc
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54 In this chapter, I will reflect
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56 hospital, there may be 50 indivi
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58 medicals, these are part of the
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60 facility and could therefore bec
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62 health. It is hoped that the Che
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64 Medication Without Harm, invites
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66 21. World Alliance for Patient S
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68 death of my late husband, Pat, f
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70 S. Sheridan et al. test. A separ
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72 enced some kind of harm due to h
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74 S. Sheridan et al. member of The
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76 6.7.1 Example: Canada 6.7.1.1 Wo
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78 All stakeholders must accept, va
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Human Factors and Ergonomics in Hea
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7 Human Factors and Ergonomics in H
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Patient Safety in the World Neelam
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8 Patient Safety in the World 95 8.
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8 Patient Safety in the World adopt
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Infection Prevention and Control An
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9 Infection Prevention and Control
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The Patient Journey Elena Beleffi,
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10 The Patient Journey 119 End of e
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10 The Patient Journey 121 Fig. 10.
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10 The Patient Journey advocates) i
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10 The Patient Journey Table 10.2 T
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10 The Patient Journey 7. Internati
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130 from these interactions that pe
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132 Data integration is certainly t
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134 organizational processes, such
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136 Table 11.3 Scheme of contributo
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138 tocol requires one or more exte
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140 system failure. Quantification
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142 8. Carayon P, editor. Handbook
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144 similar industries, in terms of
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146 (2002) argue is a more effectiv
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148 for research in patient safety
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150 hospital in Kenya with focus on
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152 Haines et al. (2002) proposed a
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154 G. Dagliana et al. Fast Track -
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156 G. Dagliana et al. 11. Jha AK,
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Part III Patient Safety in the Main
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162 development of new receptor ant
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164 Physician burnout and the psych
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166 S. Damiani et al. Fig. 13.1 In
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168 mortality and has rapidly becom
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170 ing to patient safety and share
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172 ability to cope with the workin
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174 2. Vlayen A, Verelst S, Bekkeri
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Safe Surgery Saves Lives Francesco
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14 Safe Surgery Saves Lives manner
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14 Safe Surgery Saves Lives not yet
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14 Safe Surgery Saves Lives In a su
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14 Safe Surgery Saves Lives 14.15.1
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14 Safe Surgery Saves Lives • Tea
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Emergency Department Clinical Risk
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15 Emergency Department Clinical Ri
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206 • Pragmatic: in a healthcare
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208 Risks associated with pregravid
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210 Table 16.1 Common and Recurrent
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212 improved clinical surveillance
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214 (only IM wards or all medical w
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216 M. L. Regina et al. Table 17.1
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218 Table 17.2 Types and preventabi
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220 nicians were certain resulted w
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224 Table 17.6 “Debiasing questio
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226 in care. At a minimum, medicati
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228 cation rates there substantiall
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230 well-structured, concise, focus
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232 M. L. Regina et al. Fig. 17.3 W
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236 Table 17.14 Risk factors for as
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238 Table 17.16 Common risk factors
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240 In patients with kidney disease
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242 Table 17.19 Clinical response t
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244 stones. Giordano’s test posit
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246 in practice. Swiss Med Wkly. 20
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248 procedures done by general inte
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250 tion: a systematic review and m
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252 162. Improvement IfH. What is a
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254 and therapeutic strategies, all
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256 direct effect of radiotherapy o
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258 obtaining treatment consent and
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260 A. Marcolongo et al. Table 18.1
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262 A. Marcolongo et al. Toxicities
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264 nies that are aimed at building
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266 A. Marcolongo et al. tissues. B
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268 and breast cancer) and can be r
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270 happened during the first three
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Page 329 and 330: 328 ical laboratory and the definit
Page 331 and 332: 330 • Findings of external accred
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Page 355 and 356: 354 scription [126]. Furthermore, a
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378 J. Braithwaite et al. Hence, cl
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380 stakeholders to figure out how
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382 J. Braithwaite et al. Clinician
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384 27.5.3 Social Networks in a War
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386 J. Braithwaite et al. Fig. 27.9
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388 representations the essential l
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390 21. Pomare C, Churruca K, Ellis
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Measuring Clinical Workflow to Impr
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28 Measuring Clinical Workflow to I
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Shiftwork Organization Giovanni Cos
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29 Shiftwork Organization influenci
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29 Shiftwork Organization Many epid
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29 Shiftwork Organization quences o
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29 Shiftwork Organization in shift
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Non-technical Skills in Healthcare
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30 Non-technical Skills in Healthca
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Medication Safety Hooi Cheng Soon,
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31 Medication Safety • Be familia
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31 Medication Safety 439 Table 31.1
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31 Medication Safety to be made bet
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31 Medication Safety medication reg
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31 Medication Safety and contexts,
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31 Medication Safety quently when m
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31 Medication Safety 31.5 Final Rec
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31 Medication Safety 451 ity and im
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31 Medication Safety 453 Open Acces
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456 studies in recent years have hi
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458 F. Ranzani and O. Parlangeli in
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460 Any difficulty encountered by t
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462 32.4.2 The Usability Assessment
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464 23. Parlangeli O, Mengoni G, Gu
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466 S. Ushiro et al. No-fault compe
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468 33.2 The Meaning of “No-Fault
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470 S. Ushiro et al. figure of 2.3
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472 S. Ushiro et al. Childbirth fac
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474 • When cerebral palsy is caus
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476 (c) (d) (e) (f) (g) (h) (i) (j)
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478 115 bpm to 80 bpm and complete
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480 • It is desirable that system
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482 cific monitoring procedures (1)
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484 Res. 2019;45(3):493-513. https:
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486 19. In the most severe cases, t
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488 Phases 3 and 4, strong emphasis
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490 Phases 5 and 6 focus is on the
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492 during a pandemic to promote tr
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494 M. Tanzini et al. the mother, p
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496 All four abilities are necessar
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